Division of Urology, Department of Surgical Oncology, University Health Network, University of Toronto, Ontario, Canada.
Division of Urology, Department of Surgical Oncology, University Health Network, University of Toronto, Ontario, Canada.
J Urol. 2017 Jan;197(1):75-83. doi: 10.1016/j.juro.2016.07.076. Epub 2016 Jul 22.
In prostate cancer biopsy Gleason score predicts stage and helps determine active surveillance suitability. Evidence suggests that small incremental differences in the quantitative percent of Gleason pattern 4 on biopsy stratify disease extent, biochemical failure following surgery and eligibility for active surveillance. We explored the overall quantitative percent of Gleason pattern 4 levels and adverse outcomes in patients with low and intermediate risk prostate cancer to whom active surveillance may be offered under expanded criteria.
We analyzed the records of patients with biopsy Gleason score 6 (3 + 3) or 7 (3 + 4) who underwent radical prostatectomy from January 2008 to August 2015. Age, prostate specific antigen, Gleason score, quantitative percent of Gleason pattern 4, overall percent positive cores (percent of prostate cancer) and clinical stage were explored as predictors of nonorgan confined disease and time to failure after radical prostatectomy.
In 1,255 patients biopsy Gleason score 7 (3 + 4) was associated with T3 or greater disease at radical prostatectomy in 35.0% compared with Gleason score 6 (3 + 3) in 19.0% (p <0.001). On multivariate analysis for each quantitative percent of Gleason pattern 4 increase there were 2% higher odds of T3 or greater disease (OR 1.02, 95% CI 1.01-1.04, p <0.001). When stratified, patients with Gleason score 7 (3 + 4) only approximated the pT3 rates of Gleason score 6 (3 + 3) when prostate specific antigen was less than 8 ng/ml and the percent of prostate cancer was less than 15%. In those cases the quantitative percent of Gleason pattern 4 had less effect. Time to failure after radical prostatectomy was worse in Gleason score 7 (3 + 4) than 6 (3 + 3) cases.
The quantitative percent of Gleason pattern 4 helps predict advanced disease and Gleason score 7 (3 + 4) is associated with worse outcomes. However, the impact of the quantitative percent of Gleason pattern 4 on adverse pathological and clinical outcomes is best used in combination with prostate specific antigen, age and disease volume since each has a greater impact on predicting nonorgan confined disease. The calculated absolute risk of T3 or greater can be used in shared decision making on prostate cancer treatment by patients and clinicians.
在前列腺癌活检中，格里森评分预测分期并有助于确定主动监测的适用性。有证据表明，活检中格里森模式 4 的定量百分比的微小增量差异可分层疾病程度、手术后生化失败以及是否符合主动监测标准。我们探讨了低危和中危前列腺癌患者的整体格里森模式 4 水平和不良结局，这些患者可能根据扩大标准接受主动监测。
我们分析了 2008 年 1 月至 2015 年 8 月期间接受根治性前列腺切除术的活检格里森评分 6（3+3）或 7（3+4）患者的记录。年龄、前列腺特异性抗原、格里森评分、格里森模式 4 的定量百分比、整体阳性核心百分比（前列腺癌百分比）和临床分期被探索为非器官局限性疾病和根治性前列腺切除术后失败时间的预测因子。
在 1255 例活检格里森评分 7（3+4）的患者中，与格里森评分 6（3+3）的 19.0%相比，在根治性前列腺切除术中发现 T3 或更高级别疾病的比例为 35.0%（p<0.001）。在每增加一个定量格里森模式 4 百分比的多变量分析中，T3 或更高级别疾病的可能性增加 2%（OR 1.02，95%CI 1.01-1.04，p<0.001）。分层后，当前列腺特异性抗原<8ng/ml 且前列腺癌百分比<15%时，格里森评分 7（3+4）患者的 pT3 率近似于格里森评分 6（3+3）患者。在这些情况下，格里森模式 4 的定量百分比的影响较小。与格里森评分 6（3+3）相比，格里森评分 7（3+4）患者的根治性前列腺切除术后失败时间更差。
格里森模式 4 的定量百分比有助于预测晚期疾病，格里森评分 7（3+4）与较差的结果相关。然而，格里森模式 4 的定量百分比对不良病理和临床结局的影响最好与前列腺特异性抗原、年龄和疾病体积结合使用，因为它们对预测非器官局限性疾病有更大的影响。通过患者和临床医生的共同决策，可以使用计算出的 T3 或更高风险的绝对风险来治疗前列腺癌。
